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Luveda Fern Kessler fell and cut her leg as she got out of bed at her Laguna Hills assisted living apartment.
It was 1:33 a.m. The 83-year-old woman did as she had been told to do: Press a personal emergency response call button, according to a recent lawsuit.
She waited, bleeding from the two-inch gash. Twenty-four minutes later, at 1:57 a.m., an unidentified staffer at Villa Valencia Health Care Center called 911, the filing says.
"Is there a nurse with the patient?" the dispatcher asks the staffer.
"No, there's not a nurse here right now,'' the staffer replied.
"OK, are you able to control the bleeding with some pressure?" the dispatcher later asks.
The staffer replies: "I'm trying to find it right now … the bleeding, where it's coming from."
Paramedics arrived at 2:10 a.m. Kessler lay on her stomach, nonresponsive. She was later pronounced dead at a local hospital.
Villa Valencia did not report the Aug. 23, 2007, incident to the state. Officials only became aware of the case after being contacted by The Orange County Register for this article.
Kessler's death has led to a wrongful death lawsuit filed in Orange County Superior Court last month against Villa Valencia and its owner, Sunrise Senior Living Inc. The 911 tape will be used as evidence in the trial, according to Richard Cohn, who represents Kessler's surviving relatives.
"They let my mom bleed to death,'' said Kessler's daughter, Joanne. "I thought that was the best place for her. … Her death was completely preventable."
Sara Krueger, a spokeswoman for Sunrise Senior Living, said she could not comment on Kessler's demise because of the pending litigation. "Sunrise's first priority is the health and safety of our residents and we take all allegations very seriously,'' she said.
She added that the company does train staffers on when to call 911, and how to assist residents while paramedics are en route. She declined to give more specifics on training.
The Virginia-based company – which runs 445 senior centers internationally – has garnered criticism in two other lawsuits this year over care of residents at Villa Valencia's adjacent nursing home unit.
In one of the cases, a jury in May awarded $2 million to the family of Mary Adams, who died in March 2005 after a brief stay at the center. Lawyers representing the Adams family argued that Villa Valencia was understaffed to give Adams adequate treatment for her pressure ulcers – which lead to her death.
Kessler, a great-grandmother, first moved to Villa Valencia in 2006 from Leisure World in Seal Beach to be closer to her family, said Joanne Kessler. She used a walker, having had both hip-and knee-replacement surgeries, and couldn't cook or clean for herself, she added.
A nurse identified Kessler as being at risk for falls, but she was not given assistance getting out of bed or going to the bathroom, the lawsuit says.
"My preference would be to have her at my house,'' said Joanne Kessler, who lives in Aliso Viejo. "But I have a condo with a tri-level. There's no way she could handle stairs. I thought, 'It was better than her being alone, back in Seal Beach.' "
Oscar Ramirez, spokesman for the state Department of Social Services, said Villa Valencia will be issued a citation because it did not report Kessler's death within seven days. The citation means that Villa Valencia has to submit a report on how it would correct similar problems in the future.
Assisted living centers are governed by less stringent regulations than nursing homes – though many of their patients have needs similar to those in nursing homes, said Michael Connors, an advocate with the nonprofit California Advocates for Nursing Home Reform.
"They're supposed to have enough staff and training to meet the person's needs," Connors said. "The problem is in both these settings the care and staffing is often inadequate and insufficient, leading to these kinds of situations."